Friday, August 23, 2013

Or, more accurately, it has declined to fund parts of it. Unfortunately, the parts it hasn’t funded include several key programs to train more primary care physicians and provide resources to those already in practice.

To be absolutely clear, the current drive by the Heritage Foundation and some members of the House and Senate to defund the entire ACA will go nowhere. There is absolutely no chance, nada, that President Obama would sign into law a spending bill that defunds his signature first term achievement, even if it means allowing the government to shutdown on October 1. (Read Eugene Robinson’s column in today’s Washington Post for a good explanation of why defunding Obamacare is a fantasy).

As we (current and former) New Yorkers, might say, fugetaboutit!

But what is being overlooked in the current defunding debate is the damage that has already been done by Congress’ refusal to fund important parts of Obamacare. I don’t mean the law’s coverage expansions—they are all funded and will go live starting October 1 (state marketplaces/exchanges) and January 1, 2015 (tax credit subsidies, federal dollars to expand Medicaid). But there is a long list of Obamacare programs that haven’t been funded, or received much less funding than originally anticipated, undermining their effectiveness. Most troubling are the underfunding/defunding of programs to address the shortage of primary care physicians.

On March 24, 2010, the Congressional Research Service issued a report to Congress on the public health, workforce and quality-related provisions in Obamacare. It is an impressive list of programs authorized by the ACA, but authorization doesn’t necessarily mean funding. The congressional appropriations process decides which “authorized” programs will be funded, and by how much, and it is here where much damage has been done. I haven’t had the time yet to go through the CRS report in detail, to see how many of the programs listed were actually funded, as opposed to those that have received zero dollars and therefore exist only on paper. But the following two stand out because I know for a fact that they have not received a dime from Congress, yet they could have done a lot of good:

National Workforce Commission: An ACP fact sheet describes the intended functions of the 15-member expert commission, which included, “Analyze, and make recommendations for, eliminating the barriers to entering and staying in primary care, including provider compensation.” It also would provide recommendations to Congress and the Administration on national health workforce priorities, goals, and policies, review current and projected health care workforce supply and demand (in consultation with relevant Federal, State and local entities), review implementation/performance of a separate State Health Care Workforce Development Grant Program also created by the ACA, assess education and training activities to determine whether demand for health care workers is being met, and study effective mechanisms for financing education and training for careers in health care. It would have made annual reports to Congress and the administration on its recommendations. John McDonough, who was a key Democratic staffer on Capitol Hill at the time that Obamacare was enacted, recalls that, “no other title of the law received such broad support and so little controversy” as did the section that authorized the National Workforce Commission. He notes that the Commission members have been appointed but, ”the Committee has been unable to hold its first meeting...As Robert Pear [reported in the February 25, 2013 edition] of the New York Times, the Commission is legally prohibited from convening -- and members are legally prohibited from communicating with each other -- because the Republican-controlled House of Representatives refuses to release the $2 million or so necessary to fund the commission's operations. Why? Because the Commission was established in the ACA, (aka: ObamaCare) and Republicans in Congress are unwilling to support anything that is part of ObamaCare, even if everyone agrees that workforce shortages represent an urgent national, state, county and local need.”

So let’s get this straight: the federal government spends, through Medicare, more than $9 billion each year on graduate medical education. The United States is facing a shortage of more than 40,000 primary care physicians for adults by the end of the decade. People in many parts of the country are already underserved. Obamacare and an aging population will increase the demand for primary care. Going without a doctor shouldn’t be a partisan issue: getting sick isn’t a function of one’s political leanings. Yet Congress can’t find $2 million out of its $3.5 trillion budget to allow a group of experts to help it figure out how to spend taxpayers’ dollars more wisely and effectively to ensure that we have enough primary care physicians (and health professionals in other fields facing shortages). Just because the National Workforce Commission is authorized by Obamacare.

Primary Care Extension Program: this program, also authorized by Obamacare, would have funded local primary care extension agencies to support and educate primary care clinicians about preventive medicine, health promotion, chronic disease management, mental health services and evidence-based therapies. The program also would have provided funding for local community health workers to provide direct assistance to primary care physicians in implementing quality improvement programs or system redesign that incorporates the principles of the Patient-Centered Medical Home (PCMH) (Congressional Research Service). The Primary Care Extension program was specifically intended to provide resources to primary care physicians in smaller practices to help them make the changes needed to successfully become PCMHs or participate in other quality improvement and system redesign initiatives, without them having to bear all of the costs themselves. The ACA provision was based on a proposal by Kevin Grumbach, MD and James Mold, MD, published by the Journal of the American Medical Association, on June 24, 2009. The authors explained that:

“New investment in primary care is necessary but not sufficient to revitalize primary care unless combined with a strategy for disseminating and implementing innovations and best practices. Acquiring an electronic health record (EHR) will not create a highly functioning medical home unless it can be used to create functional patient registries. Receiving enhanced payments for care coordination without a workable plan for hiring and training health coaches for patient self-management leaves a gap between expectations and reality. Large, organized delivery systems such as Geisenger, Kaiser Permanente, and the Veterans Administration have the institutional wherewithal and economies of scale to implement practice redesign in a systematic and successful manner. However, two-thirds of office-based physicians work in practices of 4 or fewer physicians. These clinicians often have little or no technical assistance to deploy and maintain new practice improvements like EHRs . . . A nationwide Primary Care Cooperative Extension Service, modeled after the US Department of Agriculture's Cooperative State Research, Education, and Extension Service (Cooperative Extension), which so successfully accelerated farm transformation, should be created. County-based health extension organizations would support primary care clinicians in the same manner that the agricultural model assists family farmers, providing infrastructure for local learning communities and practice transformation.”

But once again, even though there is bipartisan support for helping primary care physicians organize their practices as PCMHs, and even though there is bipartisan recognition that this is particularly challenging for primary care physicians in smaller practices, Congress hasn’t funded this innovative program to help smaller primary care practices make the transition, because it is part of Obamacare, and you know, the House of Representatives won’t fund any part of Obamacare if they can help it.

There are many, many more Obamacare programs that haven’t received funding from Congress, including many dozens of programs intended to support primary care, because of the unrelenting efforts by some conservatives to kill and defund the entire law, even the parts that, in a less polarized and partisan world, would have bipartisan support. Like getting expert advice on how to spend federal dollars more wisely to ensure that we have enough primary care physicians. Or helping primary care physicians in smaller practices survive.

The “defund Obamacare” camp will not be able to block funding for the Obamacare coverage expansions that will go into effect this fall and next year. But by “defunding” other parts of Obamacare, they are making it harder for the patients, who will get coverage, to find a doctor.

Today’s questions: What do you think of the effort to defund Obamacare, all of it, even though there is almost no plausible scenario where it can succeed, and even if it leads to a government shutdown? What do you think will be the impact of Congress having already “defunded” programs to help increase the number of primary care physicians and provide help to those already in practice?

Friday, August 16, 2013

It doesn’t. If anything, it will strengthen it, as I’ll explain later in this post. But many of the law’s fiercest critics keep saying that Obamacare will “destroy” the patient-physician relationship. Yet there is little if anything they can point to that is actually in Obamacare that would get between patients and their physicians.

Typical is a letter that Docs4PatientCare, a self-described” organization of “concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship” wants physicians to give to their patients. The letter “to all of my patients” is written as if it is coming from a patient’s own personal physician when it really was written and produced by a national advocacy organization. The letter, which was originally distributed prior to the 2010 mid-term elections, claims that “This new law politicizes medicine and in my opinion destroys the sanctity of the doctor-patient relationship that makes the American health care system the best in the world” and expressly threatens retribution against Democratic candidates for Congress. “Please remember when you vote this November that unless the Democratic party receives a strong negative message about this power grab our health care system will never be fixed and the doctor patient relationship will be ruined forever.” Finally, the letter concludes by telling the patients that the doctor “will be glad to discuss this with you at the end of our consultation.”

(Before I get into the lack of support for their argument about Obamacare bringing ruin to the patient-physician relationship, isn’t this group’s efforts to hijack a physician’s medical consultation with a patient to “send a strong negative message” to Democratic candidates about Obamacare, in itself destructive of the patient-physician relationship, and even borderline unethical? The AMA’s Council on Ethical and Judicial Affairs cautions that “Conversations about political matters are not appropriate at times when patients or families are emotionally pressured by significant medical circumstances.” When is a patient more emotionally pressured and vulnerable than in a medical consultation with their doctor? What is more political than a physician telling them how they should vote?)

Now back to their point about Obamacare destroying the patient-doctor relationship. The letter says that Section 1311 of the ACA (Obamacare) establishes “care-guidelines that your doctor must abide by or face penalties and fines. In making doctors answerable in the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions.”

Except Section 1311 doesn’t say that, and you won’t find it anywhere else in Obamacare. You can look it up here and you’ll find that Section 1311 describes the benefits that health plans must offer to patients in order to be sold on the state health insurance marketplaces. It establishes certification criteria for qualified health plans, requiring such plans to “meet marketing requirements, ensure a sufficient choice of providers, include essential community providers in their networks, be accredited on quality, implement a quality improvement strategy, use a uniform enrollment form, present plan information in a standard format, and provide data on quality measures.” It also requires that health plans “publicly disclose, in plain language, information on claims payment policies, enrollment, denials, rating practices, out-of-network cost sharing, and enrollee rights . . . and requires such plans to provide information to enrollees on the amount of cost sharing for a specific item or service.”

This destroys the patient-physician relationship how? It seems to me that providing patients with more choices of health insurance, better benefits, and transparent information on claims payment policies, enrollments, denials, out-of-network cost-sharing would be good for the doctor-patient relationship.

The Docs4PatientCare letter could be referring to another section of the law that continues the Medicare Physician Reporting Program, a program that was in affect long before Obamacare became law. The PQRS uses a carrots and sticks approach of positive updates and penalties depending on how well physicians do on reporting on quality measures for the Medicare population. One can take certainly take issue with the program and even philosophically disagree with linking payments to performance measures, but to say it destroys the patient-physician relationship is an over-reach. (Others might argue that it has the potential to improve the patient-physician relationship, because the purpose of the program is to improve outcomes to patients.)

And, the idea of linking physician payments to performance measures is hardly unique to or the creation of Obamacare. In case you weren’t paying attention, the Energy and Commerce Committee’s bill to repeal the Medicare SGR, which was developed by the Republican majority and received unanimous support from all of the members of the committee, Democrats and Republicans alike, would mandate an even more robust pay-for-performance program for Medicare beginning in 2019. As I wrote in an earlier blog post, “The bipartisan message from Congress is clear: if physicians choose to remain only in FFS, their annual updates going forward will be very modest, 0.5% for the next five years, and no more than 1.5% and as low as -0.5% depending on where they rank in the new quality reporting system that would begin in 2019. (And if they don’t participate in the quality reporting system at all, or one of the Alternative Payment Models, they would get an annual 5% cut).”

The Docs4PatientCare letter continues with the inevitable “rationing by government panels” charge against Obamacare. But where in Obamacare would you find these government rationing panels? You won’t, because they don’t exist. It could be that they are referring to the much maligned and misunderstood Medicare Independent Payment Advisory Board (IPAB), a board that hasn’t yet been appointed, that will be made up of independent experts--not government bureaucrats—nominated by the President and confirmed by the Senate (assuming that the President’s nominees could get confirmed, which would be no sure thing) ,that is purely advisory to Congress (Congress can accept or reject its recommendations), that is empowered to make recommendations to Congress to reduce Medicare spending only if a statutory spending threshold is exceeded, which isn’t expected to happen for several more years, and that is expressly prohibited from reducing benefits or rationing care. IPAB is by no means perfect, but it is at most a paper tiger, and even if/when it is appointed and confirmed and starts making recommendations to Congress, which Congress can then accept or reject, it will still be just an expert advisory group that is expressly prohibited from rationing care. You don’t need to take my word for it. Read what independent fact-checking sites have ruled:

“But the law doesn’t establish any kind of board that would make decisions on what care seniors get as they’re waiting in hospital beds, or anywhere else. . . .the Independent Payment Advisory Board, cannot, by law, ‘ration’ care or determine which treatments Medicare covers. In fact, the IPAB is limited in what it can do to curb the growth of Medicare spending” concluded FactCheck.

Addressing a claim from a 2012 Senate candidate that “the patient-doctor relationship will be eliminated" under Obamacare, the Pulitzer Prize winning PolitiFact ruled it as “pants on fire” falsehood: “That’s a hefty charge. And there’s little proof to substantiate it. Provisions in the health care law allow changes to payments to health care providers and influence what’s covered by certain insurance plans, but nothing in the bill prevents physicians and patients from making health care decisions together.”

So what else in Obamacare might threaten the doctor-patient relationship? The Heritage Foundation claims that it “Destroys the doctor-patient relationship. Obamacare’s massive amount of red tape and regulations will tear apart the doctor-patient relationship. Doctors will have to focus increasingly on government rules rather than the specific needs of their patients . . . In addition, Obamacare links payment for providers to adherence to government measurements of care.“

I’ve already addressed the misleading claim that “Obamacare links payment for providers to government measures of care”—it only continued the Medicare quality reporting program that was already in effect. And the measures used in that program aren’t government measures, they came from physician specialty societies and other clinical experts.

I agree that physicians are faced with too much paperwork, and that this can weaken the patient-physician relationship, but the Heritage Foundation piece doesn’t name any specific regulations from Obamacare that will “tear apart” the doctor-patient relationship. The truth is that almost all of Obamacare’s rules are imposed on insurance companies, not on physicians. The rules on insurance companies are mostly about making sure that they provide adequate benefits, spend most of the premium dollar on patient care rather profit and administration, and that they don’t turn people down because they are sick. On the other hand, Obamacare requires insurance companies to standardize enrollment procedures and codes edits used to flag claims for further review, standardize the process for determining patient eligibility, to standardize electronic funds transfers, and standardize rules for the administrative transactions including health claims; referral; certification; and authorization requirements.

To sum up: there are no rationing panels in Obamacare, no bureaucrats telling doctors what treatments they can and can’t provide to their patients. Obamacare continues the existing Medicare pay-for-reporting program (PQRS), but to be fair, the idea of linking physician payments has strong bipartisan support in Congress and is the linchpin of the Republican-drafted bill to repeal the Medicare SGR. Obamacare imposes more rules on insurance companies so that they will be required to offer better benefits, spend more money on patient care, and standardize health insurance transactions, but such rules can actually help the doctor-patient relationship by financial reducing barriers to patients getting the care their physician recommends and by simplifying claims processing.

In other words, there is nothing, nada, to support the claim that Obamacare will destroy the patient-physician relationship, but there is much in it that can strengthen it. Because the biggest benefit of Obamacare is that it will provide access to affordable health insurance for tens of millions of patients. The Institute of Medicine has found that:

“Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. Uninsured children are 20 to 30 percent more likely to lack immunizations, prescription medications, asthma care, and basic dental care. Uninsured children with conditions requiring ongoing medical attention, such as asthma or diabetes, are 6 to 8 times more likely to have unmet health care needs. Uninsured children are also more likely than insured children to miss school due to health problems and to experience preventable hospitalizations. Among working-age uninsured adults, 40 percent have one or more chronic health conditions such as asthma, hypertension, depression, diabetes, chronic lung disease, cancer, or heart disease. Uninsured adults with such chronic conditions are two to four times more likely than their insured counterparts to have received no medical attention in the prior year. Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services . . .“

So what could be better for strengthening the patient-physician relationship than giving patients access to affordable health insurance coverage, as Obamacare will do, so that they don’t need to “delay or forgo doctors’ visits, prescription medications, and other effective treatments?”

Today’s questions: How do you think Obamacare will affect the patient-physician relationship? And if you think it will “harm” or even “destroy it” tell me how, tell me what exactly in the law does this?

Friday, August 2, 2013

I think we all have fantasies from time-to-time of what we might do if we were made King for a day (only benevolent kings, of course—no despots need apply!) What decrees might we issue to make the world a better place? What changes would we order to make our politics better? What improvements would we institute to make health care better? Well, here’s my (health care) list:

1. I would decree that every American will have guaranteed access to health insurance coverage that can’t be taken away. (In the context of the current state of American politics, I would give the people and their elected lawmakers a choice: work to ensure that Obamacare covers everyone as originally intended, or pass another program that would cover as many or more people.) The one option I would not allow to continue is a system that denies access to tens of millions of people.

2. I would free physicians from the stranglehold of paperwork, rules, and mandates that do not improve patient care. I would implement a single, paperless billing system for all payers. I would order the makers of electronic health records to create ones that really make it easier for physicians to deliver better care, rather than imposing more burdens on them. I would require that all existing and new rules and regulations meet two simple standards: are they absolutely needed to protect the public and improve care, and are they achieving this objective in the least burdensome way possible? If not, get rid of them.

3. I would make medical education free for physicians who go into primary care and I would put them at the top of the physician pay scale. I would remind the people that there is no one more valuable to patients and the health care system, than a well-trained primary care internist, family physician, or pediatrician.

4. I would order a ceasefire in the ongoing interprofessional battle between physicians and nurses, giving them 24 hours to reach an agreement on their respective roles and responsibilities in patient care, with the only requirement that the agreement must put the interests of patients first, not their own territorial interests.

5. I would decree that all hospitals, physicians, drug manufacturers and medical suppliers disclose their prices in advance, and I would require insurers to disclose how much of that price they will cover, in an Expedia-type format that would allow consumers (and their physicians in making referrals) to shop around for the best price.

6. I would decree that patients also have access to understandable and accurate measures of the quality of care provided by the hospitals and physicians in their communities, and patients’ experience with the care they received, so that patients (and their physicians in making referrals) could shop around for the best quality and price (see #5 above).

7. I would direct government and health insurers to allow physicians to innovate in how medical care is organized and delivered, rather than imposing the flavor of the day (ACOs anyone?) on them, as long as they can show that the innovation improves outcomes and lowers cost.

8. I would impose common-sense controls to reduce firearm injuries and deaths, including universal background checks and a ban on high-capacity ammunition.

9. I would repeal the Medicare SGR (enough said).

10. I would make our political system work again, by banning big money contributions (yeah, I know the Supreme Court said I can’t, but remember, I’m the King in my fantasy!), by making Senators really talk non-stop if they are going to declare a filibuster to impede legislation or appointments, by banning political gerrymandering of legislative districts, and by telling Congress that the art of governance requires compromise, and they have one week to produce a federal budget that reverses sequestration and ensures funding for essential health programs, that takes the debt ceiling off the table (once and for all), that ends the war over Obamacare, and that reforms entitlements and taxes. And then, and only after they agreed to these conditions, would I resign my position on the throne and turn power back to them.

Okay, back to reality. I know that in the real world no one is going to make me King. Yeah, I know in my heart that democracy, for all of its flaws, is a better system than benign dictatorship. I know all of the reasons why most of my fantasy wish list is considered to be unrealistic in the real world of public policy and politics.

But yet, is my wish list really too much to expect from elected lawmakers in Washington who take a solemn oath to a Constitution that requires them to promote the common welfare and ensure domestic tranquility? Is it too much to ask that we provide every American with health insurance, that we free doctors from unnecessary red tape and paperwork, that we enact policies that support the value of primary care, that physicians and nurses put aside their differences so that they can work together to provide the best possible care to patients, that we facilitate choice and completion by posting comparative information on price and quality, that we keep guns out of the hands of insane people and convicted felons and that we limit access to guns that allow murderers to kill as many people as possible in as little time as possible (including schoolchildren), that we repeal the ridiculous SGR formula, and that we reform our politics so government can actually start governing again? Is that really too much of a fantasy to ask of the people we elect?

Today’s questions: If you were King, what changes would you make in our health care system and politics? What do you think of my list?